Bile duct injuries and outcomes: a retrospective medical record review

Objective: To report on our experience of cholecystectomy associated bile duct injuries and observe factors influencing outcomes

Study Design: Simple descriptive study

Place and Duration of Study: Surgical unit IV, Military Hospital [MH] Rawalpindi, over a period of seven years from 01-01-2005 to 1-12-2012

Material and Methods: Eighty eight patients who underwent repair of bile duct injuries during this period were included in this study. Patients referred from class 'W and 'C' hospitals to our institute were also included

Results: Fifteen immediate repairs [0-72 hours] post cholecystectomy, forty eight intermediate repairs [72hrs-6wks] and twenty five late repairs [> 6 wks] were performed [table-1]. Short term morbidity was higher in patients with upper biliary tract injury [p=.04].The most common long-term complication was biliary stricture, which occurred in 28 patients [31.8%]. Patients with bile duct injuries [BDIs] repaired in intermediate period were more prone to develop stricture of biliary tree than those repaired in immediate or late period [p=.03] [table 3]. Long term morbidity was also higher in patients who presented with bile contamination of peritoneum [p=.03] and had sustained complex biliary tract injuries [E4/E5] [p=.03].The overall morbidity and mortality rate was 31% and 3% respectively

Conclusion: We observed that complex hilar injury, presence of intra-abdominal bile and timing of BDI repair is an important predictor of long-term outcome. Injuries repaired in early [0-72hrs] or late period [>6wks] were less likely to develop biliary stricture as compared to injuries repaired in intermediate period [72hrs-6wks]. Moreover complex hilar injuries and intra-abdominal bile at presentation increases the possibility for development of late biliary stricture

Outcome of close reduction and percutaneous pinning in displaced pediatric supracondylar fracture of humerus assessed by Flynn's criteria

To evaluate the adequacy of closed reduction and percutaneous Kirschner [K]-wire fixation technique in treatment of unstable type II and III supracondylar humeral fractures in children by Flynn's Criteria. A descriptive study. Combined Military Hospital / Military Hospital Rawalpindi, from August 2008 to September 2012 Children with displaced type II and III supracondylar fractures of the humerus who were managed with closed reduction and percutaneous K-wire fixation were included. All patients were operated upon within three days after trauma. Patients were followed up for a mean period of 4 +/- 1 months and assessed radiologically for union. Functionally and cosmetically they were assessed according to Flynn's criteria. Eighty nine children with displaced type II and III supracondylar fractures of the humerus were managed with closed reduction and percutaneous K-wire fixation. There were 67 boys and 22 girls with a mean age of 7.2 +/- 2.07 year. All patients achieved solid union. Functionally, 94.4% patients achieved excellent and good while 4.5% had satisfactory results. Cosmetically 86.5% of patients had excellent and good results, 5.6% satisfactory and 7.9% had unsatisfactory results. The most frequent complication was minor pin tract infection in seven patients. Two patients had neuraprexia of ulnar nerve after pinning. The obtained results and few complications noted suggest that the technique is a suitable treatment option for displaced type II and III supracondylar fractures in children, if referred early

Alvarado score; validity in diagnosing acute appendicitis

To determine the validity of Alvarado score in diagnosing acute appendicitis keeping histopathology of appendix as gold standard. Cross sectional [Validation] study. Department of Surgery Combined Military Hospital Rawalpindi from April 2009 to October 2009. 90 patients with clinical suspicion/diagnosis of acute appendicitis were included in study. All were divided into two groups on the basis of Alvarado score. Group I with score 7-10, who underwent open appendicectomy. Group ll [a] with 5-6, who were observed in hospital. Group ll [b] with< 4 were discharged. In all operated cases appendix was sent for histopathology. Alvarado score was compared with histopathology [gold standard] Male to female ratio was 3.5 :1. Mean age was 25.34. Alvarado score had overall 88.13% sensitivity, 70.96% specificity, 85.24% PPV. 75.86% NPV and 16.90% negative appendicectomy rate. Whereas in male patients it had 90.74% sensitivity, 75% specificity, 92.45% PPV, 70.58%NPV and 6.89% negative appendicectomy rate. In female it had 60% sensitivity, 66.66% specificity, 37.5% PPV, 83.33%NPV and 38.46% negative appendicectomy rate. Alvarado score is very accurate for acute appendicitis in male patients. Patients with score 4 can safely be discharged home. USG should be performed routinely in female patients to improve the diagnostic accuracy of Alvarado score

Patterns of presentation and outcome in critical limb ischemia

The threatened limb due to peripheral occlusive arterial disease, embolism or trauma requires early recognition and urgent treatment if the limb is to be saved. To determine the pattern of presentation and outcome of surgery in cases of critical limb ischemia. Descriptive study. This study was conducted at surgical ward, Combined Military Hospital, Rawalpindi, from Dec 2006 to Dec 2007. A sample size of 30 patients was taken by convenience sampling. Informed written consent was obtained from all patients. Patients suffering from rest pain with ischemia features, trophic lesions, extensive gangrene, ulcers and demonstrable presence of occlusive arterial disease were included in the study. Moribund patients, extensive cardiopulmonary disease or advanced malignancy were not included in the study. Thirty patients were included in the study. The mean age was 56 +/- 13. There were 28 males [93.3%] and 2 females [6.7%]. They were all married and belonged to middle and low middle social economic class. Out of 30, there were 2 [6.7%] cases of trauma while 28 [93.3%] had peripheral vascular involvement secondary to thromboembolism. Vessels involved were femoral artery in 9 [30%] cases, popliteal artery in 18 [60%] cases and brachial artery in 2 [6.7%] cases. Rest pain was present as a primary feature in all the patients [100%], while tissue loss or gangrene was seen in 22 [73.33%] cases. A total of 14 [46.7%] amputations, 6 [20%] bypass procedures, 4 [13.3%] lumbar sympathectomies, and 2 [6.7%] embolectomies, were carried out, whereas 4 [13.3%] patients were managed conservatively. Of the patients having rest pain 46.7% were amputated, whereas of patients having ischemic tissue loss 73.3% were amputated. 13 patients who underwent primary amputation had ankle brachial pressure index [ABPI less than 0.4 [86.7%]. ABPI was more than 0.4 in 4 [13.3%] patients whereas it was less than 0.4 in 26 [86.7%] patients. Overall, critical leg ischemia has a very poor prognosis. If surgical, or endovascular, improvement of the blood supply to the leg is not provided in due course; half of the legs will be amputated within a year. One of the main goals of vascular surgery is to prevent major amputations

Comparison of conventional gauze therapy with vacuum assisted closure wound therapy in acute traumatic wounds

To compare the Vacuum Assisted Closure [VAC] wound therapy with Conventional Gauze Therapy [CGT] in management of acute traumatic wounds on the basis of time taken to achieve a vital red wound ready for definitive surgical closure. Randomized control trial. Department of Surgery Combined Military Hospital Rawalpindi from Mar 2009 to Sep 2009. This study included 82 patients of acute traumatic wounds. Patients were randomly allotted to group A, in which wound was treated with new method of vacuum assisted closure [VAC] wound therapy and to group B, in which wound was managed by conventional gauze therapy [CGT]. Outcomes were measured by the presence of vital red wound ready to be closed by surgical intervention. Patients with concomitant systemic pathology were not included in study. Comparison between the two groups revealed mean time for wound healing 13 days in group A and 16.9 days in group B with significant difference [p value =0.029]. Vacuum assisted closure wound therapy is an effective method in reducing time of wound healing for definitive surgical closure

Analysis of causes and treatment modality in non-union of long bones diaphyseal fractures

The purpose of this study was to analyze the causes of nonunion leading to modification in treatment modalities in long bones diaphyseal fractures. Descriptive Study. Combined Military Hospital Quetta, Combined Military Hospital Sialkot, Pakistan, from 5th Sep 2005 to 26th Dec 2008. Non-healing long bones diaphyseal fractures > 6 months were included with exclusion of pathological fractures, delayed union < 6 months. Patients general profile and fracture details with non-union causes were recorded. Old failed surgery with re-do surgical intervention was analyzed. Infected cases were treated with removal of implant, thorough debridment, appropriate antibiotics followed by delayed stabilization while non-infected cases with stable fixation and bone grafting. Out of fifty six patients, tibial fractures were maximum 17[30.4%], femur 16[28.6%], radius ulna 15[26.6%], and humerus 8[14.3%]. Most patients were young 37[66.07%] and male 48[85.7%]. Road traffic accident caused 43[76.8%] fractures. Causes of non-union were high energy trauma 37[66%], insufficient stabilization 31[55.4%], followed by smoking, soft tissue interposition, poor nutrition, NSAIDs, broken implants, infection, intact fellow bone, multiple segment fracture, repeated manipulation, chronic illness and neurovascular impairment in descending order. Plates failed more than K nails. Complications like superficial and deep infection, neuroprexia and delayed healing settled with bone healing in mean time 4.76 months. Nonunion of long bones diaphyseal fractures can be prevented by avoiding causative agents, early intervention, tissue protection and stable fixation. Interlock nailing is best for femur, good for tibia, may be useful in humerus but not suitable for radius and ulna. Bone graft accelerates healing process. Early re do surgery must be considered because of manageable rate of complications

Partial weight bearing; new quantitative approach

The objective of this study was to quantify scientifically the partial weight bearing advice to the patients so that the treating surgeons and treated patients know exactly how much weight they should bear on the treated limb. Descriptive study. The study was conducted at combined military hospital Sialkot and combined military Hospital Quetta from May, 2003 to Dec, 2006. We studied 150 patients who were operated for osteosynthesis in lower limb. We excluded all patients below age 10 years, poly trauma patients operated for bilateral leg fractures, and associated upper limb fractures. Patients were advised to place studied limb on weighing machine and exert required force. Depending upon implant used, quality of fixation and bone density, 5 to 10 kilogram of weight bearing was started two to three weeks after the operation. This force was gradually increased by 5 to 10 kilograms two weekly interval as union progressed. Average age of the patients was about 40 years most of them were young males, with 5:1 ratio to females. Femur was most commonly involved bone in 81 [54%] patients, while tibia in 69 [46%] patients. Road traffic accident was most common etiology in 95 [63.33%] patients, history of fall, nonunion, and field injuries were etiology in other cases. Locally made implants were used in all cases. External fixator was applied in 45 [30%] and internal fixation was done in 105 [70%] cases. Bone grafting was done in 24 cases. We achieved union in 97.3% patients. Union was achieved in mean 15.1 weeks in internal fixations and 17.3 weeks in external fixators. We had 21 [14%] minor and 8 [5%] major complications most of them in patients requiring external fixators. Quantifying partial weight bearing advice gives confidence to patient that how much weight bearing to be done depending upon fracture geometry, implant used its fixation and bone quality. By avoiding nonspecific terms toe touch, heel touch and partial weight bearing we can advise exactly to bear required weight by this simple method. The result of study shows excellent union rates even in open fractures and infected nonunion. To our knowledge this is the first attempt to quantify partial weight bearing advice. The result of this study will help in understanding the patient regarding weight bearing

Management of thoracic injuries: our experience at military hospitals

Thoracic trauma is a major health care problem accounting for a significant percentage of the morbidity and mortality associated with the management of trauma patients. We performed a prospective study with the purpose to review our experience of the management of thoracic injuries at military hospitals having no proper thoracic surgical set up. The study was conducted at Combined Military Hospital Quetta and Combined Military Hospital Peshawar from January 2001 to September 2005 and a total of 84 cases of thoracic trauma with blunt and penetrating injury were managed. Mean age of patients was 36.5 years and female to male ratio was 1:13. Penetrating trauma was more common cause, 51 [61.7%] cases of chest injuries as compared to the blunt trauma 33 [39.3%] cases. The clinical conditions resulting ribs fractures in 73 cases [86.9%], flail chest in 3 patients [3.57%], haemothorax in 24 [28.57%] cases, pneumothorax in 8 [9.52%] cases, haemo-pneumothorax in 43 [51.19%] cases, pulmonary contusions in 5 [5.95%] cases, bronchial injury in 1 patient [1.19%], ruptured left diaphragm in 5 [5.95%] with herniation of abdominal contents in the left chest in 2 patients. Bilateral thoracic involvement was seen in 3 cases [3.57%]. Right chest was involved in 48 patients [57.14%] while the left in 36 patients [42.86%]. Extra-thoracic associated injuries were seen in 33 [39.3%] cases. Cardiac, great vessels, thoracic duct and esophageal injuries were not encountered during the course of this study. Seventy seven patients [91.66%] were treated initially with tube thoracostomy and it alone was effective in 69 patients [89.61%]. Overall thoracotomy rate was 9.52% [8 cases]. Emergency thoracotomy was performed in 3 [3.57%] cases and delayed thoracotomy in 5 [5.95%] cases. Empyema thoracic was seen in 3 patients [3.9%] with tube thoracostomy. Overall percentage of empyema was 3.57%. Seven patients [8.33%] were managed without the need of either tube thoracostomy or thoracotomy. Minor complications of tube thoracostomy were seen in 10 cases [12.99%]. Overall mortality rate was 3.57% [3 deaths]. Tube thoracostomy remains the most effective treatment modality in the management of most of the cases of chest trauma

Intravenous paracetamol is as effective as morphine in knee arthroscopic day surgery procedures

To conduct a prospective randomized study comparing the analgesic effect of Intravenous Paracetamol with Intravenous Morphine in postoperative pain control of patients undergoing knee arthroscopic surgery as day cases. Eighty four patients were randomised into two groups on the basis of the last digit of their medical number. Odd numbers were given Paracetamol [Group-I] and even Morphine [Group-II]. All patients underwent Examination under Anaesthesia [E.U.A] and knee arthroscopy +/- a partial menisectomy as day cases and had to stay of a minimum of 4 hours post surgery. A standardize General Anaesthesia was given to both groups. An intra-articular injection of 20mls of 0.5% Marcaine was given to all patients. Postoperative pain was assessed up to 4 hours using the Verbal Rating Scale [V.R.S.]. The adverse effects of the drugs were also observed. Of 84 patients, 76 were males and 8 females. The age range was from 18 to 69 years, weighing from 55 to 90kg. Paracetamol [Group-I] had 43 patients and there were 41 patients in the Morphine [Group-II] Group. The results according to VRS, from 0 to 4 hours showed no difference in the analgesic effect of the two groups, but much less adverse effect were noted in Group-I. In our study both intravenous Paracetamol and Intravenous Morphine seems to have the same analgesic effect. However, side effects with Intravenous Paracetamol were much less

Radiation to patients during dynamic HIP screw surgery

The aim of this study was two fold. To determine the diagnostic reference level [D.R.L.] dose of radiation during dynamic hip screw [D.H.S.] fixation and, to audit the orthopaedic department against this standard. A retrospective analysis of 112 consecutive patients between 31[st] December 2002 and the 6[th] July 2003, at Darenth Valley Hospital, Dartford, under going dynamic hip screw fixation for proximal femur fractures was carried out. The data was collected from the Radiographers log. The screening time and Dose Area Product [DAP] for each event was analyzed in conjunction with the Radiation Protection Department at Kings College, London. Taking the 75[th] percentile from the existing data, the DAP was set at 1.05cGy/cm[2]. The screening time for the procedure was set at 64.2 seconds. An audit to access the performance of the orthopaedic department against these standards was carried out. All grades of surgeons performing this procedure were included in the audit. In the total of 112 patients, there were 32 males and 80 females. The age range was from 27 to 99 years with a mean of 83.96 years. Sixty fractures were on the right side and 52 on the left. The total screening time for the procedures was 78.25 minutes with an average of 0.877 of a minute [i.e.] 52.62 seconds. The total Dose Area Product [DAP] was 96.42cGy/cm[2] with an average of 0.860cGy/cm[2]. At present there are no DRL for orthopedic procedures locally or nationally in the United Kingdom, despite this being a legal requirement since May 2000. The authors have determined a local DRL for DHS fixation which can be used as a guideline for this procedure. We recommend that DRL be set for other orthopedic procedures done under Fluoroscopic guidance, especially procedure involving younger patient

Mass Casualty management after a suicidal terrorist attack on a religious procession in Quetta, Pakistan

To determine the effectiveness of hospital management, considering triage system, hospital staff response, medical resources availability, and surgical management depending upon the nature and pattern of injuries in a mass casualty incident. Descriptive. Combined Military Hospital, Quetta, Pakistan in March 2004. All injured by gunshot or blast in a terrorist attack and reported to the hospital were included in this study. Patients were triaged by the triage team using "triage sieve" into priority I, II, III, and IV. Priority I patients were further triaged by using "trauma index" to prioritize for surgery. Phase I included life saving, Phase II limb saving surgery and Phase III for debridement. All data was recorded and analyzed. Hospital received 161 casualties among whom 20 were brought in dead, and 141 patients were admitted to the hospital. Mean age was 26.63 +/- 13.97.The cases were categorized as Priority-I 22.7%, Priority-II 14.72%, Priority-III 50.31% and Priority-IV 12.27%. Maximum casualties reached within the first 2 hours. Eighty-eight patients had pre-dominantly splinter injuries and 53 patients had dominantly gunshot wound injuries. In priority I, the trauma index was 15.55 +/- 5.74. Six patients having trauma index 20 or above could not even be resuscitated. Seventyfive percent of staff reported to the hospital within 15 minutes. Only 30% of reserve medical store was consumed. Total management cost to the hospital was Rs. 362,1856/- [British Pounds approx 32,052/-.] calculated by the hospital rates for treatment of non-entitled patients. Death rate in hospital survivors was 4%. Mass casualty management in a terrorist act requires prompt hospital response, appropriate triage, efficient surgical approach, and dedicated postoperative care. A good response can help to decrease mortality rate in salvageable injuries

Per-cutaneous transhepatic cholangiography in obstructive jaundice by using lumbar puncture needle

To assess the effectiveness of per-cutaneous transhepatic cholangiography [PTC] with 22G lumbar puncture [LP] needle in obstructive Jaundice. The study was carried out at CMH Muzaffarabad and CMH Sialkot from January 2003 to March 2006. Twenty two patients were included in our study who underwent PTC for evaluation of obstructive Jaundice. PTC was done in these patients using ordinary LP needles [22 G] instead of Chiba needle under fluoroscopic guidance. Preliminary ultrasound scan and coagulation profile were done in all patients. Of 22 patients 12 were males, and 10 females, their mean age being 55+ 10 years. Intra hepatic and extra hepatic channels were opacified with 100% accuracy. Growth / masses and stones were commonest causes of obstructive jaundice. Out of growth and masses, cholangiocarcinomas [including Klatskin tumor] and carcinoma head of pancreas were more common. PTC related complications were nil. PTC can be successfully performed in cases of obstructive jaundice with ordinary LP needle [22 G]. This is cost effective, simple and less time consuming

Planned external fixation to locked intramedullary nailing conversion for open fractures of shaft of femur and tibia

To determine the outcome of initial external fixation and then conversion to intramedullary nailing in patients having open fracture of shaft of femur or tibia. Design: Descriptive study. Place and Duration of Study: Combined Military Hospital [CMH], Quetta, from July 2002 to July 2004. Subjects and Out of 59 patients with fractures of shaft of tibia and femur, 16 were selected for the study who had open fractures in Gustilio type I, II and III. They were initially managed with external fixators and later on converted to planned locked intramedullary nailing. Interlocking nailing was done on routine operation list in the third week after Ex Fix [external fixator] was removed. Record of patients was kept, and was statistically analyzed on SPSS. Out of the16 patients, 12 had fractures of femur and 4 had fractures of tibia. Male to female ratio was 7:1. Mean duration of external fixation was 6.22 weeks. Six patients underwent closed interlocking nailing and 10 patients with open method. Fifteen fractures [94%] united within 6 months, and one fracture had delayed union. Two patients had superficial wound infection and one patient had deep infection. Immediate external fixation followed by early closed interlocking nailing is a safe and effective treatment for open fractures of shaft of femur and tibia

Triage and management of mass casualties in a train accident

The purpose of this study was to assess the practicality and usefulness of different scoring systems of triage process in mass casualty management. Design: Descriptive/observational. Place and Duration of Study: An experience of management of train accident in Balochistan in the year 2003. Subjects and One hundred and twenty-two patients injured in train accident of Quetta Express were included in the study. A trauma team reached the site of the accident. Triage was done at three levels. "Triage sieve" scoring system was used at the site of accident, "field categories of trauma patients" at Primary Health Care Centre, and "ATLS [Advanced Trauma Life Support] secondary survey" at tertiary referral centre. Helicopters and ambulances were used for evacuation of patients. There were 122 injured patients. " Triage sieve " system scored 14[11.47%] patients in priority I, 21[17.21%] patients in priority II, 80[65.57%] patients in priority III and 7[5.73%] dead individuals in priority IV at the site of accident. Casualties clearing time was three and half hours. By utilizing "field categories of trauma patients" at primary health care centre, 7[5.7%] patients were placed in category I who were air lifted, 19[15.57%] patients in category II, 89[72.95%] patients in category III and 7[5.73%] dead remained in category IV. Application of ATLS secondary survey in CMH, Quetta triaged 4[57.14] patients in priority I and 3[42.85] patients in priority II. There was only one death after the triage process started. Proper triage, appropriate resuscitation, and timely evacuation definitively decrease morbidity and mortality in trauma patients, and facilitates utilization of the available resources appropriately